Bipolar Disorder

Bipolar disorder

Definition

Bipolar, or manic-depressive disorder, is a mood disorder that causes radical emotional changes and mood swings, from manic highs to depressive lows. The majority of bipolar individuals experience alternating episodes of mania and depression.

Bipolar I disorder is characterized by manic episodes, the "high" of the manic-depressive cycle. A person with bipolar disorder experiencing mania often has feelings of self-importance, elation, talkativeness, increased sociability, and a desire to embark on goal-oriented activities, coupled with the characteristics of irritability, impatience, impulsiveness, hyperactivity, and a decreased need for sleep . Usually this manic period is followed by a period of depression, although a few bipolar I individuals may not experience a major depressive episode. Mixed states, where both manic or hypomanic symptoms and depressive symptoms occur at the same time, also occur frequently with bipolar I patients (for example, depression with the racing thoughts of mania). Also, dysphoric mania is common (mania characterized by anger and irritability).

Bipolar II disorder is characterized by major depressive episodes alternating with episodes of hypomania, a milder form of mania. Bipolar depression may be difficult to distinguish from a unipolar major depressive episode. Patients with bipolar depression tend to have extremely low energy, retarded mental and physical processes, and more profound fatigue (for example, hypersomnia, a sleep disorder marked by a need for excessive sleep or sleepiness when awake) than unipolar depressives.

Cyclothymia refers to the cycling of hypomanic episodes with depression that does not reach major depressive proportions. One third of patients with cyclothymia develop bipolar I or II disorder later in life.

A phenomenon known as rapid cycling occurs in up to 20 percent of bipolar I and II patients. In rapid cycling, manic and depressive episodes must alternate frequently, at least four times in 12 months, to meet the diagnostic definition. In some cases of "ultra-rapid cycling" the patient may bounce between manic and depressive states several times within a 24-hour period. This condition is very hard to distinguish from mixed states.

Bipolar NOS is a category for bipolar states that do not clearly fit into the bipolar I, II, or cyclothymia diagnoses.

Demographics

According to the American Academy of Child and Adolescent Psychiatry, up to one third of American children and adolescents diagnosed with depression develop early onset bipolar disorder. The average age of onset of bipolar disorder is from adolescence through the early twenties. However, because of the complexity of the disorder, a correct diagnosis can be delayed for several years or more. In a survey of bipolar patients conducted by the National Depressive and Manic Depressive Association (MDMDA), one half of respondents reported visiting three or more professionals before receiving a correct diagnosis, and over one third reported waiting ten years or more before they were correctly diagnosed.

Causes and symptoms

The cause of bipolar disorder had not as of 2004 been clearly defined. Because two thirds of bipolar patients have a family history of affective or emotional disorders, researchers have searched for a genetic link to the disorder. Several studies have uncovered a number of possible genetic connections to the predisposition for bipolar disorder. A 2003 study found that schizophrenia and bipolar disorder could have similar genetic causes that arise from certain problems with genes associated with myelin development in the central nervous system. (Myelin is a white, fat-like substance that forms a sheath around nerve fibers.) Another possible biological cause under investigation is the presence of an excessive calcium build-up in the cells of bipolar patients. Dopamine and other neurochemical transmitters appear to be implicated in bipolar disorder, and these are under investigation as well.

Over one-half of patients diagnosed with bipolar disorder have a history of substance abuse, which may be an issue in adolescent patients. There is a high rate of association between cocaine abuse and bipolar disorder. Some studies have shown up to 30 percent of abusers meet the criteria for bipolar disorder. The emotional and
physical highs and lows of cocaine use correspond to the manic depression of the bipolar patient, making the disorder difficult to diagnose.

For some bipolar patients, manic and depressive episodes coincide with seasonal changes. Depressive episodes are typical during winter and fall, and manic episodes are more probable in the spring and summer months.

When to call the doctor

When symptoms of bipolar disorder are present, a child should be taken to a qualified medical healthcare professional as soon as possible for evaluation. If a child or teen diagnosed with bipolar disorder reveals at any time that they have had recent thoughts of self-injury or suicide , or if they demonstrate behavior that compromises their safety or the safety of others, professional assistance from a mental healthcare provider or care facility should be sought immediately.

Diagnosis

Bipolar disorder usually is diagnosed and treated by a psychiatrist and/or a psychologist. In addition to an interview with the child and her parents, several clinical inventories or scales may be used to assess the patient's mental status and determine the presence of bipolar symptoms. These include the Children's Global Assessment Scale (C-GAS), General Behavior Inventory (GBI), Beck Depression Inventory (BDI), Minnesota Multiphasic Personality Inventory Adolescent (MMPI-A), the Youth Inventory (YI-4), and the Young Mania Rating Scale (YMRS). The tests are verbal and/or written and are administered in both hospital and outpatient settings.

Bipolar symptoms often present differently in children and adolescents. Manic episodes in these age groups are typically characterized by more psychotic features than in adults, which may lead to a misdiagnosis of schizophrenia. Children and adolescents also tend to demonstrate irritability and aggressiveness instead of the elation of mania in adults. Further, symptoms tend to be chronic, or ongoing, rather than acute, or episodic. Bipolar children are easily distracted, impulsive, and hyperactive, which can lead to a misdiagnosis of attention deficit hyperactivity disorder (ADHD). Their aggression can lead to violence, which may be misdiagnosed as a conduct disorder .

Psychologists and psychiatrists typically use the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV ) as a guideline for diagnosis of bipolar disorder and other mental illnesses. DSM-IV describes a manic episode as an abnormally elevated or irritable mood lasting a period of at least one week that is distinguished by at least three of the mania symptoms: inflated self-esteem , decreased need for sleep, talkativeness, racing thoughts, distractibility, increase in goal-directed activity, or excessive involvement in pleasurable activities that have a high potential for painful consequences. If the mood of the patient is irritable and not elevated, four of the symptoms are required.

Although many clinicians find the criteria too rigid, a hypomanic diagnosis requires a duration of at least four days with at least three of the symptoms indicated for manic episodes (four if mood is irritable and not elevated). DSM-IV notes that unlike manic episodes, hypomanic episodes do not cause a marked impairment in social or occupational functioning, do not require hospitalization , and do not have psychotic features. In addition, because hypomanic episodes are characterized by high energy and goal-directed activities and often result in a positive outcome or are perceived in a positive manner by the patient, bipolar II disorder can go undiagnosed.

Substance abuse can mask or mimic the presence of bipolar disorder and can make diagnosis more difficult in adolescents. When substance abuse or addiction is present, a patient must ordinarily undergo a period of detoxification and abstinence before a mood disorder can be accurately diagnosed.

Treatment

The manic and depressive symptoms of bipolar disorder are usually controlled by a combination of prescription medications, including lithium, antipsychotics, anticonvulsants, and antidepressants .

Lithium

Lithium (Cibalith-S, Eskalith, Lithane, Lithobid, Lithonate, Lithotabs) is one of the oldest and most frequently prescribed drugs available for the treatment of adult bipolar mania and depression. Because the drug takes four to ten days to reach a therapeutic level in the bloodstream, it sometimes is prescribed in conjunction with neuroleptics and/or benzodiazepines to provide more immediate relief of a manic episode. Lithium also has been shown to be effective in regulating bipolar depression, but is not recommended for mixed mania. Lithium may not be an effective long-term treatment
option for rapid cyclers, who typically develop a tolerance for it, or may not respond to it. Possible side effects of the drug include weight gain, thirst, nausea , and hand tremors. Prolonged lithium use also may cause hyperthyroidism .

Antipsychotics

Clozapine (Clozaril) is an atypical antipsychotic medication used to control manic episodes in adult patients who have not responded to typical mood stabilizing agents. The drug has also been a useful prophylactic, or preventative treatment, in some bipolar patients. Common side effects of clozapine include tachycardia (rapid heart rate), hypotension, constipation , and weight gain. Agranulocytosis, a potentially serious but reversible condition in which the white blood cells that typically fight infection in the body are destroyed, is a possible side effect of clozapine. Patients treated with the drug should undergo weekly blood tests to monitor white blood cell counts.

Risperidone (Risperdal) is another atypical antipsychotic that has been successful in controlling mania in several clinical trials when low doses were administered. The side effects of risperidone are mild compared to many other antipsychotics (constipation, coughing, diarrhea , dry mouth, headache , heartburn, increased length of sleep and dream activity, nausea, runny nose, sore throat , fatigue, and weight gain).

Olanzapine (Zyprexa) was approved in 2003 for use in combination with lithium or valproate for treatment of acute manic episodes associated with bipolar disorder. In 2004 it received additional approval for long-term maintenance of bipolar disorder. Possible side effects include drowsiness, dizziness , weight gain, dry mouth, rapid heartbeat, nausea, and muscle weakness.

Quetiapine (Seroquel) was approved by the FDA in 2004 for the treatment of acute mania associated with bipolar disorder. Potential side effects of the drug include dizziness, sleepiness, dry mouth, weight gain, and constipation.

Ziprasidone (Geodon) is a schizophrenia drug that is often prescribed to treat bipolar mania. Common side effects associated with ziprasidone include dizziness, fatigue, constipation, and rash. Unlike the other antipsychotic drugs, however, it does not promote weight gain.

Atypical antipsychotics have been associated with hyperglycemia (high blood sugar) and diabetes in some patients. Their use may be contraindicated (i.e., not recommended) in children and teens with type 1 or type 2 diabetes.

Anticonvulsants

Valproate (divalproex sodium, or Depakote; valproic acid, or Depakene) is one of the few drugs available that has been proven effective in treating rapid cycling bipolar and mixed states patients. It is also approved for the treatment of mania. Valproate is prescribed alone or in combination with carbamazepine and/or lithium. Stomach cramps, indigestion, diarrhea, hair loss, appetite loss, nausea, and unusual weight loss or gain are some of the common side effects of valproate. A 2003 study found that the risk of suicide from death is about two and one half times higher in people with bipolar disorder taking divalproex than those taking lithium.

Gabapentin (Neurontin) has been prescribed by some physicians for the treatment of bipolar disorder, although there is no conclusive clinical evidence as to its effectiveness.

Carbamazepine (Tegretol, Atretol) is an anticonvulsant drug usually prescribed in conjunction with other mood stabilizing agents. The drug often is used to treat bipolar patients who have not responded well to lithium therapy. Blurred vision and abnormal eye movement are two possible side effects of carbamazepine therapy. Clinical trials continue as of 2004 in an attempt to obtain FDA approval of carbamazepine for use in bipolar treatment.

Lamotrigine (Lamictal, or LTG), an anticonvulsant medication, is often used in patients with a history of rapid cycling and antidepressant-induced mania. A University of Cincinnati one-year study of the drug in patients with bipolar I disorder found that it provided sustained relief of depressive symptoms. Lamotrigine may be used in conjunction with divalproex (divalproate) and/or lithium. Possible side effects of lamotrigine include skin rash, dizziness, drowsiness, headache, nausea, and vomiting .

Antidepressants

Because antidepressants may stimulate manic episodes in some bipolar children and teens, their use is typically short-term. Some researchers have hypothesized that the use of antidepressants for depression may even trigger bipolar disorder in children who are genetically predisposed.

When antidepressants are prescribed for episodes of bipolar depression, they are usually selective serotonin reuptake inhibitors (SSRIs) or, less often, monoamine oxidase inhibitors (MAO inhibitors). Tricyclic antidepressants used to treat unipolar depression may trigger rapid cycling in bipolar patients and are, therefore, not a preferred treatment option for bipolar depression.

MAOIs such as tranylcypromine (Parnate) and phenelzine (Nardil) block the action of monoamine oxidase (MAO), an enzyme in the central nervous system. Patients taking MAOIs must cut foods high in tyramine (found in aged cheeses and meats) out of their diet to avoid hypotensive side effects.

Bupropion (Wellbutrin) is a heterocyclic antidepressant. The exact neurochemical mechanism of the drug is not known, but it has been effective in regulating bipolar depression in some patients. Side effects of bupropion include agitation, anxiety, confusion, tremor, dry mouth, fast or irregular heartbeat, headache, and insomnia.

In 2004, 10 antidepressant drugs (including fluoxetine, sertraline, paroxetine, and bupropion) came under scrutiny when the FDA issued a public health advisory and announced it was requesting the addition of a warning statement in drug labeling that outlined the possibility of worsening depression and increased suicide risk. These developments were the result of several clinical studies that found that some children taking these antidepressants had an increased risk of suicidal thoughts and actions. The FDA announced at the time that the agency would embark on a more extensive analysis of the data from these clinical trials and decide if further regulatory action was necessary.

Electroconvulsive therapy

Electroconvulsive therapy (ECT) has a high success rate for treating both unipolar and bipolar depression and mania. However, because of the convenience of drug treatment and the stigma sometimes attached to ECT therapy, ECT usually is employed after all pharmaceutical treatment options have been explored. ECT is given under anesthesia, and patients are given a muscle relaxant medication to prevent convulsions. The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient's head. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that this electrical current alters the electrochemical processes of the brain, consequently relieving depression. Headaches, muscle soreness, nausea, and confusion are possible side effects immediately following an ECT procedure. Temporary memory loss has also been reported in ECT patients. In bipolar patients, ECT is often used in conjunction with drug therapy.

Adjunct therapies

Other drugs that may be use as adjunct therapies (i.e., in addition to regular treatment) to treat manic episodes include the following:

Calcium channel blockers: Nimodipine (Nimotop, Admon) and verapamil (Calan, Covera, Isoptin), typically used to treat angina and hypotension, have been found effective in a few small studies, for treating rapid cyclers. Calcium channel blockers stop the excess calcium build up in cells that is thought to be a cause of bipolar disorder. They usually are used in conjunction with other drug therapies such as carbamazepine or lithium.

Long-acting benzodiazepines: Lorazepam (Ativan), clonazepam (Klonapin), and alprazolam (Xanax) are used for rapid treatment of manic symptoms to calm and sedate patients until mania or hypomania have waned and mood stabilizing agents can take effect. Sedation is a common effect, and clumsiness, lightheadedness, and slurred speech are other possible side effects of benzodiazepines.

Neuroleptics: Chlorpromazine (Thorazine) and haloperidol (Haldol) are also used to control mania while a mood stabilizer such as lithium or valproate takes effect. Because the side effects of these drugs can be severe (difficulty in speaking or swallowing, paralysis of the eyes, loss of balance control, muscle spasms , severe restlessness, stiffness of arms and legs, tremors in fingers and hands, twisting movements of body, and weakness of arms and legs), benzodiazepines are generally preferred over neuroleptics.

Because bipolar disorder is thought to be biological in nature, therapy and/or counseling is recommended as a companion to, but not a substitute for, pharmaceutical treatment of the disease. Psychotherapy, such as cognitive-behavioral therapy, can be a useful tool in helping patients and their families adjust to the disorder, in encouraging compliance to a medication regimen, and in reducing the risk of suicide. A 2003 report revealed that people on medication for bipolar disorder had better results if they also participated in family-focused therapy.

Alternative treatment

General recommendations include maintaining a calm environment, avoiding overstimulation, getting plenty of rest, regular exercise , and proper diet. Biofeedback may be effective in helping some children and adolescents control symptoms such as irritability, poor self control, racing thoughts, and sleep problems. A diet low in vanadium (a mineral found in meats and other foods) and high in vitamin C may be helpful in reducing depression.

Repeated transcranial magnetic stimulation (rTMS) is a new and still experimental treatment for the depressive phase of bipolar disorder. In rTMS, a large magnet is placed on the patient's head and magnetic fields of different frequency are generated to stimulate the left front cortex of the brain. Unlike ECT, rTMS requires no anesthesia and does not induce seizures.

Prognosis

While most children show some positive response to treatment, response varies widely, from full recovery to
a complete lack of response to all drug and/or ECT therapy. Drug therapies frequently need adjustment to achieve the maximum benefit for the patient. Bipolar disorder is a chronic recurrent illness in over 90 percent of those afflicted, and one that requires lifelong observation and treatment after diagnosis. Patients with untreated or inadequately treated bipolar disorder have a suicide rate of 15 to 25 percent and a nine-year decrease in life expectancy. With proper treatment, the life expectancy of the bipolar patient will increase by nearly seven years and work productivity increases by 10 years.

According to the American Psychiatric Association, bipolar children and adolescents experiencing a manic episode have a one-year recovery rate of 37.1 percent and a relapse rate of 38.3 percent. Discontinuing lithium treatment too early may increase the risk of relapse in adolescents with bipolar disorder. In one 1990 study, 92 percent of adolescents hospitalized for mania who stopped taking the drug experienced a relapse of symptoms within 18 months of discharge, compared to 37 percent of those who stayed on lithium therapy.

Children and teens with bipolar disorder are at a greater risk for substance abuse than their non-bipolar peers, and substance abuse can worsen or complicate bipolar treatment. In a 1999 two-year follow-up study of adolescents hospitalized for manic episodes, patients who had ongoing drug or alcohol abuse problems had more manic episodes and poorer functioning than those patients who were not substance abusers. In addition, some studies have indicated that children who develop bipolar disorder in adolescence are more likely to develop a substance abuse problem than those who have early-onset of bipolar disorder in childhood.

Prevention

The ongoing medical management of bipolar disorder is critical for preventing relapse, or recurrence, of manic episodes. Even in carefully controlled treatment programs, bipolar patients may experience recurring episodes of the disorder. Education in the form of psychotherapy or self-help groups is crucial for training bipolar patients and their caregivers to recognize signs of mania and depression and to take an active part in their treatment program.

Parental concerns

Children with bipolar disorder may require special accommodations in the classroom. Section 504 of the Rehabilitation Act of 1973 enables parents to develop both a Section 504 plan (which describes a child's medical needs) and an individualized education plan (IEP), which describes what special accommodations a child requires to address those needs. The IEP may cover issues such as allowing extra time on tests, modifying assignments, and providing home tutoring or a classroom aide when necessary.

Children who are diagnosed with bipolar disorder should be reassured that the condition is due to factors beyond their control (i.e., genetics, neurochemical imbalance) rather than any fault of their own. For those children and teens who feel stigmatized or self-conscious about their diagnosis, arranging psychotherapy sessions outside school hours may lessen their burden. Any child on prescription medication for bipolar disorder should be carefully monitored for any sign of side effects, and these should be reported to their physician when they do occur. A dosage adjustment or medication change may be warranted if side effects are disruptive or potentially dangerous.

KEY TERMS

Anticonvulsant—Drugs used to prevent convulsions or seizures. They often are prescribed in the treatment of epilepsy.

Antipsychotic drug—A class of drugs used to control psychotic symptoms in patients with psychotic disorders such as schizophrenia and delusional disorder. Antipsychotics include risperidone (Risperdal), haloperidol (Haldol), and chlorpromazine (Thorazine).

Benzodiazepine—One of a class of drugs that have a hypnotic and sedative action, used mainly as tranquilizers to control symptoms of anxiety. Diazepam (Valium), alprazolam (Xanax), and chlordiazepoxide (Librium) are all benzodiazepines.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition(DSM-IV)—This reference book, published by the American Psychiatric Association, is the diagnostic standard for most mental health professionals in the United States.

Electroconvulsive therapy (ECT)—A psychological treatment in which a series of controlled electrical impulses are delivered to the brain in order to induce a seizure within the brain. This type of therapy is used to treat major depression and severe mental illness that does not respond to medications.

Hyperthyroidism—A condition characterized by abnormal over-functioning of the thyroid glands. Patients are hypermetabolic, lose weight, are nervous, have muscular weakness and fatigue, sweat more, and have increased urination and bowel movements. Also called thyrotoxicosis.

Hypomania—A milder form of mania that is characteristic of bipolar II disorder.

Mania—An elevated or euphoric mood or irritable state that is characteristic of bipolar I disorder. This state is characterized by mental and physical hyperactivity, disorganization of behavior, and inappropriate elevation of mood.

Mixed mania—A mental state in which symptoms of both depression and mania occur simultaneously. Also called mixed state.

Neurotransmitter—A chemical messenger that transmits an impulse from one nerve cell to the next.

Bipolar disorder

Bipolar disorder

Definition

Bipolar, or manic-depressive, disorder is a mood disorder that causes radical emotional changes and mood swings, from manic highs to depressive lows. The majority of bipolar individuals experience alternating episodes of mania (an elevated or euphoric mood or irritable state) and depression.

Description

In the United States alone, bipolar disorder afflicts an estimated three million people. According to a report by the National Institutes of Mental Health, the disorder costs over $45 billion annually. The average age of onset of bipolar disorder is from adolescence through the early twenties. However, because of the complexity of the disorder, a correct diagnosis can be delayed for several years or more.

Bipolar I disorder is characterized by manic episodes, the "high" of the manic-depressive cycle. A bipolar patient experiencing mania often has feelings of self-importance, elation, talkativeness, increased sociability, and a desire to embark on goal-oriented activities, coupled with the characteristics of irritability, impatience, impulsiveness, hyperactivity, and a decreased need for sleep. Usually this manic period is followed by a period of depression, although a few bipolar I individuals may not experience a major depressive episode. Mixed states, where both manic or hypomanic symptoms and depressive symptoms occur at the same time, also occur frequently with bipolar I patients (for example, depression with the racing thoughts of mania). Also, dysphoric mania is common (mania characterized by anger and irritability).

Bipolar II disorder is characterized by major depressive episodes alternating with episodes of hypomania, a milder form of mania. Bipolar depression may be difficult to distinguish from unipolar depression (depression without mania, as found in major depressive disorder ). Patients with bipolar depression tend to have extremely low energy, retarded mental and physical processes, and more profound fatigue (for example, hypersomnia—a sleep disorder marked by a need for excessive sleep or sleepiness when awake) than people with unipolar depression.

Cyclothymia refers to the cycling of hypomanic episodes with depression that does not reach major depressive proportions. A third of patients with cyclothymia will develop bipolar I or II disorder later in life.

A phenomenon known as rapid cycling occurs in up to 20% of bipolar I and II patients. In rapid cycling, manic and depressive episodes must alternate frequently—at least four times in 12 months—to meet the diagnostic definition. In some cases of "ultra-rapid cycling," the patient may bounce between manic and depressive states several times within a 24-hour period. This condition is very hard to distinguish from mixed states.

Bipolar NOS is a category for bipolar states that do not clearly fit into the bipolar I, II, or cyclothymia diagnoses.

Causes and symptoms

The source of bipolar disorder has not been clearly defined. Because two-thirds of bipolar patients have a family history of emotional disorders, researchers have searched for a genetic link to the disorder. Several studies have uncovered a number of possible genetic connections to the predisposition for bipolar disorder. There is significant evidence that correlates bipolar II with genetic causes. Studies have shown that identical twins have an 80% concordance rate (presence of the same disorder). Additionally, studies have demonstrated that the disorder is transmitted to children by autosomal dominant inheritance. This means that either affected parent (father or mother) has a 50% chance of having a child (regardless if the child is male or female) with the disorder.

Further studies concerning the genetic correlations have revealed specific chromosomes (the structures that contain genes) that contain mutated genes. Susceptible genes are located in specific regions of chromosomes 13, 18, and 21. The building blocks of genes, called nucleotides, are normally arranged in a specific order and quantity. If these nucleotides are repeated, a genetic abnormality usually results. Recent evidence suggests that a special type of nucleotide repeat is observed in persons with bipolar II on chromosome 18. However, the presence of this sequence does not worsen the disorder or change the age of onset. It is currently thought that expression of bipolar II involves multiple mutated genes. Further research is ongoing to discover precise mechanisms and to develop genetic markers (gene tags) that would predict which individuals are at higher risk.

Another possible biological cause for bipolar disorder under investigation is the presence of an excessive calcium buildup in the cells. Also, dopamine and other neurochemical transmitters (the chemicals that transmit messages from nerve cell to nerve cell) appear to be implicated in bipolar disorder and these are under intense investigation.

Over half of patients diagnosed with bipolar disorder have a history of substance abuse. There is a high rate of association between cocaine abuse and bipolar disorder. Some studies have shown up to 30% of abusers meeting the criteria for bipolar disorder. The emotional and physical highs and lows of cocaine use correspond to the manic depression of the bipolar patient, making the disorder difficult to diagnose.

For some bipolar patients, manic and depressive episodes coincide with seasonal changes. Depressive episodes are typical during winter and fall, and manic episodes are more probable in the spring and summer months.

Symptoms of bipolar depressive episodes include low energy levels, feelings of despair, difficulty concentrating, extreme fatigue, and psychomotor retardation (slowed mental and physical capabilities). Manic episodes are characterized by feelings of euphoria, lack of inhibitions, racing thoughts, diminished need for sleep, talkativeness, risk taking, and irritability. In extreme cases, mania can induce hallucinations and other psychotic symptoms such as grandiose delusions (ideas that the person affected is extremely important or has some unrecognized talent or insight).

Demographics

Manic-depression is a common psychological disorder that is difficult to detect. As stated, it is estimated that about three million people in the United States are affected. The disorder is more common among women than men. Women have been observed at increased risk of developing subsequent episodes in the period immediately following childbirth.

Diagnosis

Bipolar disorder is usually diagnosed and treated by a psychiatrist and/or a psychologist with medical assistance. In addition to an interview, several clinical inventories or scales may be used to assess the patient's mental status and determine the presence of bipolar symptoms. These include the Millon Clinical Multiaxial Inventory III (MCMI-III), Minnesota Multiphasic Personality Inventory II (MMPI-2), the Internal State Scale (ISS), the Self-Report Manic Inventory (SRMI), and the Young Mania Rating Scale (YMRS). The tests are verbal and/or written and are administered in both hospital and outpatient settings.

Psychologists and psychiatrists typically use the criteria listed in the DSM-IV-TR as a guideline for diagnosis of bipolar disorder and other mental illnesses. DSM-IV-TR describes a manic episode as an abnormally elevated or irritable mood lasting a period of at least one week that is distinguished by at least three of the mania symptoms: inflated self-esteem, decreased need for sleep, talkativeness, racing thoughts, distractibility, increase in goal-directed activity, or excessive involvement in pleasurable activities that have a high potential for painful consequences. If the mood of the patient is irritable and not elevated, four of the symptoms are required.

Although many clinicians find the criteria too rigid, a hypomanic diagnosis requires a duration of at least four days with at least three of the symptoms indicated for manic episodes (four if mood is irritable and not elevated). DSM-IV-TR notes that unlike manic episodes, hypomanic episodes do not cause a marked impairment in social or occupational functioning, do not require hospitalization , and do not have psychotic features (no delusions or hallucinations). In addition, because hypomanic episodes are characterized by high energy and goal-directed activities and often result in a positive outcome, or are perceived in a positive manner by the patient, bipolar II disorder can go undiagnosed.

Bipolar symptoms often appear differently in children and adolescents than they appear in adults. Manic episodes in these age groups are typically characterized by more psychotic features than in adults, which may lead to a misdiagnosis of schizophrenia . Children and adolescents also tend toward irritability and aggressiveness instead of elation. Further, symptoms tend to be chronic, or ongoing, rather than acute, or episodic. Bipolar children are easily distracted, impulsive, and hyperactive, which can lead to a misdiagnosis of attention-deficit/hyperactivity disorder (ADHD). Furthermore, their aggression often leads to violence, which may be misdiagnosed as a conduct disorder .

Substance abuse, thyroid disease, and use of prescription or over-the-counter medication can mask or mimic the presence of bipolar disorder. In cases of substance abuse, the patient must ordinarily undergo a period of detoxification and abstinence before a mood disorder is diagnosed and treatment begins.

Treatment

Bipolar disorder is usually treated with both medical and psychosocial interventions. Psychosocial therapies address both psychological and social issues.

Medical interventions

A combination of mood-stabilizing agents with antidepressants, antipsychotics, and anticonvulsants is used to regulate manic and depressive episodes.

MOOD-STABILIZING AGENTS. Mood-stabilizing agents such as lithium, carbamazepine , and valproic acid (valproate) are prescribed to regulate the manic highs and lows of bipolar disorder:

Lithium (lithium carbonate , Cibalith-S, Eskalith, Lithane, Lithobid, Lithonate, Lithotabs) is one of the oldest and most frequently prescribed drugs available for the treatment of bipolar mania and depression. Because the drug takes four to ten days to reach a therapeutic level in the bloodstream, it is sometimes prescribed in conjunction with neuroleptics (other psychiatric drugs) and/or benzodiazepines (medications that ease tension by slowing down the central nervous system) to provide more immediate relief of a manic episode. Lithium has also been shown to be effective in regulating bipolar depression, but is not recommended for mixed mania. Lithium may not be an effective long-term treatment option for rapid cyclers, who typically develop a tolerance for it, or may not respond to it. Possible side effects of the drug include weight gain, thirst, nausea, and hand tremors. Prolonged lithium use may also cause hyperthyroidism (a disease of the thryoid marked by heart palpitations, nervousness, the presence of goiter, sweating, and a wide array of other symptoms.)

Carbamazepine (Tegretol, Atretol) is an anticonvulsant drug (a drug to treat seizures ) usually prescribed in conjunction with other mood-stabilizing agents. The drug is often used to treat bipolar patients who have not responded well to lithium therapy. Blurred vision and abnormal eye movement are two possible side effects of carbamazepine therapy.

Valproic acid (divalproex sodium , or Depakote; valproate, or Depakene) is one of the few drugs available that has been proven effective in treating rapid cycling bipolar and mixed states patients. Valproate is prescribed alone or in combination with carbamazepine and/or lithium. Stomach cramps, indigestion, diarrhea, hair loss, appetite loss, nausea, and unusual weight loss or gain are some of the common side effects of valproate.

ANTIDEPRESSANTS. Because antidepressants may stimulate manic episodes in some bipolar patients, their use is typically short-term. Selective serotonin reuptake inhibitors (SSRIs) or, less often, monoamine oxidase inhibitors (MAO inhibitors) are prescribed for episodes of bipolar depression. Tricyclic antidepressants used to treat unipolar depression may trigger rapid cycling in bipolar patients and are, therefore, not a preferred treatment option for bipolar depression.

SSRIs, such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil), regulate depression by regulating levels of serotonin, a neurotransmitter. Anxiety, diarrhea, drowsiness, headache, sweating, nausea, sexual problems, and insomnia are all possible side effects of SSRIs.

MAOIs such as tranylcypromine (Parnate) and phenelzine (Nardil) block the action of monoamine oxidase (MAO), an enzyme in the central nervous system. Patients taking MAOIs must cut foods high in tyramine (found in aged cheeses and meats) out of their diet.

Bupropion (Wellbutrin) is a heterocyclic antidepressant. The exact neurochemical mechanism of the drug is not known, but it has been effective in regulating bipolar depression in some patients. Side effects of bupropion include agitation, anxiety, confusion, tremor, dry mouth, fast or irregular heartbeat, headache, and insomnia.

ADJUNCT TREATMENTS. Adjunct treatments are used in conjunction with a long-term pharmaceutical treatment plan:

Long-acting benzodiazepines (medications that ease tension by slowing the central nervous system) such as clonazepam (Klonapin) and alprazolam (Xanax) are used for rapid treatment of manic symptoms to calm and sedate patients until mania or hypomania have waned and mood-stabilizing agents can take effect. Sedation is a common effect, and clumsiness, light-headedness, and slurred speech are other possible side effects of benzodiazepines.

Neuroleptics (antipsychotic medications) such as chlorpromazine (Thorazine) and haloperidol (Haldol) are also used to control mania while a mood stabilizer such as lithium or valproate takes effect. Because neuroleptic side effects can be severe (difficulty in speaking or swallowing, paralysis of the eyes, loss of balance control, muscle spasms, severe restlessness, stiffness of arms and legs, tremors in fingers and hands, twisting movements of body, and weakness of arms and legs), benzodiazepines are generally preferred over neuroleptics.

ECT, or electroconvulsive therapy , has a high success rate for treating both unipolar and bipolar depression, and mania. However, because of the convenience of drug treatment and the stigma sometimes attached to ECT therapy, ECT is usually employed after all pharmaceutical treatment options have been explored. ECT is given under anesthesia and patients are given a muscle relaxant medication to prevent convulsions. The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient's head. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that this electrical current alters the electrochemical processes of the brain, consequently relieving depression. Headaches, muscle soreness, nausea, and confusion are possible side effects immediately following an ECT procedure. Temporary memory loss has also been reported in ECT patients. In bipolar patients, ECT is often used in conjunction with drug therapy.

Calcium channel blockers (nimodipine, or Nimotop), typically used to treat angina and hypotension (low blood pressure), have been found effective, in a few small studies, for treating rapid cyclers. Calcium channel blockers stop the excess calcium buildup in cells that is thought to be a cause of bipolar disorder. They are usually used in conjunction with other drug therapies such as carbamazepine or lithium.

Clozapine (Clozaril) is an antipsychotic medication used to control manic episodes in patients who have not responded to typical mood-stabilizing agents. The drug has also been a useful prophylactic, or preventative treatment, in some bipolar patients. Common side effects of clozapine include tachycardia (rapid heart rate), hypotension, constipation, and weight gain. Agranulocytosis, a potentially serious but reversible condition in which the white blood cells that typically fight infection in the body are destroyed, is a possible side effect of clozapine. Patients treated with the drug should undergo weekly blood tests to monitor white blood cell counts.

Risperidone (Risperdal) is an antipsychotic medication that has been successful in controlling mania in several clinical trials when low doses were administered. The side effects of risperidone are mild compared to many other antipsychotics (constipation, coughing, diarrhea, dry mouth, headache, heartburn, increased length of sleep and dream activity, nausea, runny nose, sore throat, fatigue, and weight gain).

A new potential treatment for bipolar II disorder may be gabapentin , an anticonvulsant that may help treat mania. Recent reports indicate that gabapentin is effective for treating sudden onset bipolar II. Very recent evidence suggests, however, that gabapentin can potentially induce aggressive and disruptive behavior in children treated with this drug for seizures.

rTMS, or repeated transcranial magnetic stimulation is a new and still experimental treatment for the depressive phase of bipolar disorder. In rTMS, a large magnet is placed on the patient's head and magnetic fields of different frequency are generated to stimulate the left front cortex of the brain. Unlike ECT, rTMS requires no anesthesia and does not induce seizures.

Psychosocial interventions

Because bipolar disorder is thought to be biological in nature, psychological therapy is recommended as a companion to, but not a substitute for, pharmaceutical treatment of the disease. Psychotherapy , such as cognitive-behavioraltherapy , can be a useful tool in helping patients and their families adjust to the disorder, in encouraging compliance to a medication regimen, and in reducing the risk of suicide . Also, educative counseling is recommended for the patient and family.

In educative counseling, patients (and their families) learn of the high rates of social dysfunction and marital discord associated with this disorder. Patients also learn how their treatment will progress, which factors can affect treatment, and what kind of follow-up after treatment will be implemented. Genetic counseling should be a part of family education programs since this disorder is more prevalent among first-degree relatives of individuals with the disorder.

Social support for individuals with bipolar disorder is also important. Some people with the disorder, as well as their families, may find support groups helpful.

Alternative treatment

General recommendations include maintaining a calm environment, avoiding over-stimulation, getting plenty of rest, regular exercise, and proper diet. Some Chinese herbs may soften mood swings, but care must be taken (and good communication with the physician is essential) when combining herbal therapies with medications. Biofeedback is effective in helping some patients control symptoms such as irritability, poor self-control, racing thoughts, and sleep problems. A diet low in vanadium (a mineral found in meats and other foods) and high in vitamin C may be helpful in reducing depression.

Prognosis

While most patients will show some positive response to treatment, response varies widely, from full recovery to a complete lack of response to all drugs and/or ECT therapy. Drug therapies frequently need adjustment to achieve the maximum benefit for the patient. Bipolar disorder is a chronic recurrent illness in over 90% of those afflicted, and one that requires lifelong observation and treatment after diagnosis. Patients with untreated or inadequately treated bipolar disorder have a suicide rate of 15-25% and a nine-year decrease in life expectancy. With proper treatment, the life expectancy of the bipolar patient increases by nearly seven years and work productivity increases by ten years.

Prevention

The ongoing medical management of bipolar disorder is critical to preventing relapse (recurrence) of manic episodes. Even in carefully controlled treatment programs, bipolar patients may experience recurring episodes of the disorder. Patient education in the form of psychotherapy or self-help groups is crucial for training bipolar patients to recognize signs of mania and depression and to take an active part in their treatment program.

Bipolar Disorder

Gale Encyclopedia of Medicine, 3rd ed.
COPYRIGHT 2006 Thomson Gale

Bipolar Disorder

Definition

Bipolar, or manic-depressive disorder, is a mood disorder that causes radical emotional changes and mood swings, from manic highs to depressive lows. The majority of bipolar individuals experience alternating episodes of mania and depression.

Description

In the United States alone, more than two million people are diagnosed with bipolar disorder. Research shows that as many as 10 million people might be affected by bipolar disorder, which is the sixth-leading cause of disability worldwide. The average age of onset of bipolar disorder is from adolescence through the early twenties. However, because of the complexity of the disorder, a correct diagnosis can be delayed for several years or more. In a survey of bipolar patients conducted by the National Depressive and Manic Depressive Association (MDMDA), one-half of respondents reported visiting three or more professionals before receiving a correct diagnosis, and over one-third reported a wait of ten years or more before they were correctly diagnosed.

Bipolar I disorder is characterized by manic episodes, the "high" of the manic-depressive cycle. A person with bipolar disorder experiencing mania often has feelings of self-importance, elation, talkativeness, increased sociability, and a desire to embark on goal-oriented activities, coupled with the characteristics of irritability, impatience, impulsiveness, hyperactivity, and a decreased need for sleep. Usually this manic period is followed by a period of depression, although a few bipolar I individuals may not experience a major depressive episode. Mixed states, where both manic or hypomanic symptoms and depressive symptoms occur at the same time, also occur frequently with bipolar I patients (for example, depression with the racing thoughts of mania). Also, dysphoric mania is common (mania characterized by anger and irritability).

Bipolar II disorder is characterized by major depressive episodes alternating with episodes of hypomania, a milder form of mania. Bipolar depression may be difficult to distinguish from a unipolar major depressive episode. Patients with bipolar depression tend to have extremely low energy, retarded mental and physical processes, and more profound fatigue (for example, hypersomnia; a sleep disorder marked by a need for excessive sleep or sleepiness when awake) than unipolar depressives.

Cyclothymia refers to the cycling of hypomanic episodes with depression that does not reach major depressive proportions. One-third of patients with cyclothymia will develop bipolar I or II disorder later in life.

A phenomenon known as rapid cycling occurs in up to 20% of bipolar I and II patients. In rapid cycling, manic and depressive episodes must alternate frequently; at least four times in 12 months; to meet the diagnostic definition. In some cases of "ultra-rapid cycling," the patient may bounce between manic and depressive states several times within a 24-hour period. This condition is very hard to distinguish from mixed states.

Bipolar NOS is a category for bipolar states that do not clearly fit into the bipolar I, II, or cyclothymia diagnoses.

Causes and symptoms

The source of bipolar disorder has not been clearly defined. Because two-thirds of bipolar patients have a family history of affective or emotional disorders, researchers have searched for a genetic link to the disorder. Several studies have uncovered a number of possible genetic connections to the predisposition for bipolar disorder. A 2003 study found that schizophrenia and bipolar disorder could have similar genetic causes that arise from certain problems with genes associated with myelin development in the central nervous system. (Myelin is a white, fat-like substance that forms a sort of layer or sheath around nerve fibers.) Another possible biological cause under investigation is the presence of an excessive calcium build-up in the cells of bipolar patients. Also, dopamine and other neurochemical transmitters appear to be implicated in bipolar disorder and these are under intense investigation.

KEY TERMS

Anticonvulsant medication— A drug used to prevent convulsions or seizures; often prescribed in the treatment of epilepsy. Several anticonvulsant medications have been found effective in the treatment of bipolar disorder.

Antipsychotic medication— A drug used to treat psychotic symptoms, such as delusions or hallucinations, in which patients are unable to distinguish fantasy from reality.

Benzodiazpines— A group of tranquilizers having sedative, hypnotic, antianxiety, amnestic, anticonvulsant, and muscle relaxant effects.

DSM-IV— Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). This reference book, published by the American Psychiatric Association, is the diagnostic standard for most mental health professionals in the United States.

ECT— Electroconvulsive therapy sometimes is used to treat depression or mania when pharmaceutical treatment fails.

Hypomania— A milder form of mania which is characteristic of bipolar II disorder.

Mixed mania/mixed state— A mental state in which symptoms of both depression and mania occur simultaneously.

Mania— An elevated or euphoric mood or irritable state that is characteristic of bipolar I disorder.

Neurotransmitter— A chemical in the brain that transmits messages between neurons, or nerve cells. Changes in the levels of certain neurotransmitters, such as serotonin, norepinephrine, and dopamine, are thought to be related to bipolar disorder.

Over one-half of patients diagnosed with bipolar disorder have a history of substance abuse. There is a high rate of association between cocaine abuse and bipolar disorder. Some studies have shown up to 30% of abusers meeting the criteria for bipolar disorder. The emotional and physical highs and lows of cocaine use correspond to the manic depression of the bipolar patient, making the disorder difficult to diagnosis.

For some bipolar patients, manic and depressive episodes coincide with seasonal changes. Depressive episodes are typical during winter and fall, and manic episodes are more probable in the spring and summer months.

Diagnosis

Bipolar disorder usually is diagnosed and treated by a psychiatrist and/or a psychologist with medical assistance. In addition to an interview, several clinical inventories or scales may be used to assess the patient's mental status and determine the presence of bipolar symptoms. These include the Millon Clinical Multiaxial Inventory III (MCMI-III), Minnesota Multiphasic Personality Inventory II (MMPI-2), the Internal State Scale (ISS), the Self-Report Manic Inventory (SRMI), and the Young Mania Rating Scale (YMRS). The tests are verbal and/or written and are administered in both hospital and outpatient settings.

Psychologists and psychiatrists typically use the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as a guideline for diagnosis of bipolar disorder and other mental illnesses. DSM-IV describes a manic episode as an abnormally elevated or irritable mood lasting a period of at least one week that is distinguished by at least three of the mania symptoms: inflated self-esteem, decreased need for sleep, talkativeness, racing thoughts, distractibility, increase in goal-directed activity, or excessive involvement in pleasurable activities that have a high potential for painful consequences. If the mood of the patient is irritable and not elevated, four of the symptoms are required.

Although many clinicians find the criteria too rigid, a hypomanic diagnosis requires a duration of at least four days with at least three of the symptoms indicated for manic episodes (four if mood is irritable and not elevated). DSM-IV notes that unlike manic episodes, hypomanic episodes do not cause a marked impairment in social or occupational functioning, do not require hospitalization, and do not have psychotic features. In addition, because hypomanic episodes are characterized by high energy and goal directed activities and often result in a positive outcome, or are perceived in a positive manner by the patient, bipolar II disorder can go undiagnosed.

Bipolar symptoms often present differently in children and adolescents. Manic episodes in these age groups are typically characterized by more psychotic features than in adults, which may lead to a misdiagnosis of schizophrenia. Children and adolescents also tend toward irritability and aggressiveness instead of elation. Further, symptoms tend to be chronic, or ongoing, rather than acute, or episodic. Bipolar children are easily distracted, impulsive, and hyperactive, which can lead to a misdiagnosis of attention deficit hyperactivity disorder (ADHD ). Furthermore, their aggression often leads to violence, which may be misdiagnosed as a conduct disorder.

Substance abuse, thyroid disease, and use of prescription or over-the-counter medication can mask or mimic the presence of bipolar disorder. In cases of substance abuse, the patient must ordinarily undergo a period of detoxification and abstinence before a mood disorder is diagnosed and treatment begins.

Treatment

Treatment of bipolar disorder is usually achieved with medication. A combination of mood stabilizing agents with antidepressants, antipsychotics, and anticonvulsants is used to regulate manic and depressive episodes.

Mood stabilizing agents such as lithium, carbamazepine, and valproate are prescribed to regulate the manic highs and lows of bipolar disorder:

Lithium (Cibalith-S, Eskalith, Lithane, Lithobid, Lithonate, Lithotabs) is one of the oldest and most frequently prescribed drugs available for the treatment of bipolar mania and depression. Because the drug takes four to ten days to reach a therapeutic level in the bloodstream, it sometimes is prescribed in conjunction with neuroleptics and/or benzodiazepines to provide more immediate relief of a manic episode. Lithium also has been shown to be effective in regulating bipolar depression, but is not recommended for mixed mania. Lithium may not be an effective long-term treatment option for rapid cyclers, who typically develop a tolerance for it, or may not respond to it. Possible side effects of the drug include weight gain, thirst, nausea, and hand tremors. Prolonged lithium use also may cause hyperthyroidism (a disease of the thryoid that is marked by heart palpitations, nervousness, the presence of goiter, sweating, and a wide array of other symptoms.)

Carbamazepine (Tegretol, Atretol) is an anticonvulsant drug usually prescribed in conjunction with other mood stabilizing agents. The drug often is used to treat bipolar patients who have not responded well to lithium therapy. Blurred vision and abnormal eye movement are two possible side effects of carbamazepine therapy.

Valproate (divalproex sodium, or Depakote; valproic acid, or Depakene) is one of the few drugs available that has been proven effective in treating rapid cycling bipolar and mixed states patients. Valproate is prescribed alone or in combination with carbamazepine and/or lithium. Stomach cramps, indigestion, diarrhea, hair loss, appetite loss, nausea, and unusual weight loss or gain are some of the common side effects of valproate. Note: valproate also is approved for the treatment of mania. A 2003 study found that the risk of death from suicide is about two and one-half times higher in people with bipolar disorder taking divalproex than those taking lithium.

Treating the depression associated with bipolar disorder has proven more challenging. In early 2004, the first drug to treat bipolar administration was approved by the U.S. Food and Drug Administration (FDA). It is called Symbyax, a combination of olanzipine and fluoxetine, the active ingredient in Prozac.

Because antidepressants may stimulate manic episodes in some bipolar patients, their use typically is short-term. Selective serotonin reuptake inhibitors (SSRIs) or, less often, monoamine oxidase inhibitors (MAO inhibitors) are prescribed for episodes of bipolar depression. Tricyclic antidepressants used to treat unipolar depression may trigger rapid cycling in bipolar patients and are, therefore, not a preferred treatment option for bipolar depression.

SSRIs, such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil), regulate depression by regulating levels of serotonin, a neurotransmitter. Anxiety, diarrhea, drowsiness, headache, sweating, nausea, sexual problems, and insomnia are all possible side effects of SSRIs.

MAOIs such as tranylcypromine (Parnate) and phenelzine (Nardil) block the action of monoamine oxidase (MAO), an enzyme in the central nervous system. Patients taking MAOIs must cut foods high in tyramine (found in aged cheeses and meats) out of their diet to avoid hypotensive side effects.

Bupropion (Wellbutrin) is a heterocyclic antidepressant. The exact neurochemical mechanism of the drug is not known, but it has been effective in regulating bipolar depression in some patients. Side effects of bupropion include agitation, anxiety, confusion, tremor, dry mouth, fast or irregular heartbeat, headache, and insomnia.

ECT, or electroconvulsive therapy, has a high success rate for treating both unipolar and bipolar depression, and mania. However, because of the convenience of drug treatment and the stigma sometimes attached to ECT therapy, ECT usually is employed after all pharmaceutical treatment options have been explored. ECT is given under anesthesia and patients are given a muscle relaxant medication to prevent convulsions. The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient's head. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that this electrical current alters the electrochemical processes of the brain, consequently relieving depression. Headaches, muscle soreness, nausea, and confusion are possible side effects immediately following an ECT procedure. Temporary memory loss has also been reported in ECT patients. In bipolar patients, ECT is often used in conjunction with drug therapy.

Adjunct treatments are used in conjunction with a long-term pharmaceutical treatment plan:

Long-acting benzodiazepines such as clonazepam (Klonapin) and alprazolam (Xanax) are used for rapid treatment of manic symptoms to calm and sedate patients until mania or hypomania have waned and mood stabilizing agents can take effect. Sedation is a common effect, and clumsiness, lightheadedness, and slurred speech are other possible side effects of benzodiazepines.

Neuroleptics such as chlorpromazine (Thorazine) and haloperidol (Haldol) also are used to control mania while a mood stabilizer such as lithium or valproate takes effect. Because neuroleptic side effects can be severe (difficulty in speaking or swallowing, paralysis of the eyes, loss of balance control, muscle spasms, severe restlessness, stiffness of arms and legs, tremors in fingers and hands, twisting movements of body, and weakness of arms and legs), benzodiazepines are generally preferred over neuroleptics.

Psychotherapy and counseling. Because bipolar disorder is thought to be biological in nature, therapy is recommended as a companion to, but not a substitute for, pharmaceutical treatment of the disease. Psychotherapy, such as cognitive-behavioral therapy, can be a useful tool in helping patients and their families adjust to the disorder, in encouraging compliance to a medication regimen, and in reducing the risk of suicide. Also, educative counseling is recommended for the patient and family. In fact, a 2003 report revealed that people on medication for bipolar disorder had better results if they also participated in family-focused therapy.

Clozapine (Clozaril) is an atypical antipsychotic medication used to control manic episodes in patients who have not responded to typical mood stabilizing agents. The drug has also been a useful prophylactic, or preventative treatment, in some bipolar patients. Common side effects of clozapine include tachycardia (rapid heart rate), hypotension, constipation, and weight gain. Agranulocytosis, a potentially serious but reversible condition in which the white blood cells that typically fight infection in the body are destroyed, is a possible side effect of clozapine. Patients treated with the drug should undergo weekly blood tests to monitor white blood cell counts.

Risperidone (Risperdal) is an atypical antipsychotic medication that has been successful in controlling mania when low doses were administered. In early 2004, the FDA approved its use for treating bipolar mania. The side effects of risperidone are mild compared to many other antipsychotics (constipation, coughing, diarrhea, dry mouth, headache, heartburn, increased length of sleep and dream activity, nausea, runny nose, sore throat, fatigue, and weight gain).

Olanzapine (Zyprexa) is another atypical antipsychotic approved in 2003 for use in combination with lithium or valproate for treatment of acute manic episodes associated with bipolar disorder. Side effects include hypotension (low blood pressure) associated with dizziness, rapid heartbeat, and syncope, or low blood pressure to the point of fainting.

Lamotrigine (Lamictal, or LTG), an anticonvulsant medication, was found to alleviate manic symptoms in a 1997 trial of 75 bipolar patients. The drug was used in conjunction with divalproex (divalproate) and/or lithium. Possible side effects of lamotrigine include skin rash, dizziness, drowsiness, headache, nausea, and vomiting.

Alternative treatment

General recommendations include maintaining a calm environment, avoiding overstimulation, getting plenty of rest, regular exercise, and proper diet. Chinese herbs may soften mood swings. Biofeedback is effective in helping some patients control symptoms such as irritability, poor self control, racing thoughts, and sleep problems. A diet low in vanadium (a mineral found in meats and other foods) and high in vitamin C may be helpful in reducing depression.

A surprising study in 2004 found that a rarely used combination of magnetic fields used in magnetic resonance imaging (MRI) scanning improved the moods of subjects with bipolar disorder. The discovery was made while scientists were using MRI to investigate effectiveness of certain medications. However, they found that a particular type of echo-planar magnetic field led to reports of mood improvement. Further studies may one day lead to a smaller, more convenient use of magnetic treatment.

Prognosis

While most patients will show some positive response to treatment, response varies widely, from full recovery to a complete lack of response to all drug and/or ECT therapy. Drug therapies frequently need adjustment to achieve the maximum benefit for the patient. Bipolar disorder is a chronic recurrent illness in over 90% of those afflicted, and one that requires lifelong observation and treatment after diagnosis. Patients with untreated or inadequately treated bipolar disorder have a suicide rate of 15-25% and a nine-year decrease in life expectancy. With proper treatment, the life expectancy of the bipolar patient will increase by nearly seven years and work productivity increases by ten years.

Prevention

The ongoing medical management of bipolar disorder is critical to preventing relapse, or recurrence, of manic episodes. Even in carefully controlled treatment programs, bipolar patients may experience recurring episodes of the disorder. Patient education in the form of psychotherapy or self-help groups is crucial for training bipolar patients to recognize signs of mania and depression and to take an active part in their treatment program.

Bipolar Disorder

Bipolar disorder

Definition

Bipolar, or manic-depressive disorder, is a mood disorder that causes radical emotional changes and mood swings, from manic highs to depressive lows. The majority of bipolar individuals experience alternating episodes of mania and depression .

Description

In the United States alone, bipolar disorder afflicts approximately 2.3 million people, and nearly 20% of this population will attempt suicide without effective treatment intervention. The average age at onset of bipolar disorder is from adolescence through the early twenties. However, because of the complexity of the disorder, a correct diagnosis can be delayed for several years or more. In a survey of bipolar patients conducted by the National Depressive and Manic Depressive Association (NDMDA), one-half of respondents reported visiting three or more professionals before receiving a correct diagnosis, and over one-third reported a wait of 10 years or more before they were correctly diagnosed.

Bipolar I disorder is characterized by manic episodes, the "high" of the manic-depressive cycle. A bipolar patient experiencing mania often has feelings of self-importance, elation, talkativeness, increased sociability, and a desire to embark on goal-oriented activities, coupled with the characteristics of irritability, impatience, impulsiveness, hyperactivity, and a decreased need for sleep. Usually this manic period is followed by a period of depression, although a few bipolar I individuals may not experience a major depressive episode. Mixed states, where both manic or hypomanic symptoms and depressive symptoms occur at the same time, also occur frequently with bipolar I patients (for example, depression with racing thoughts of mania). Also, dysphoric mania is common (mania characterized by anger and irritability).

Bipolar II disorder is characterized by major depressive episodes alternating with episodes of hypomania, a milder form of mania. Bipolar depression may be difficult to distinguish from a unipolar major depressive episode. Patients with bipolar depression tend to have extremely low energy, retarded mental and physical processes, and more profound fatigue (for example, hypersomnia; a sleep disorder marked by a need for excessive sleep or sleepiness when awake) than unipolar depressives.

Cyclothymia refers to the cycling of hypomanic episodes with depression that does not reach major depressive proportions. One-third of patients with cyclothymia will develop bipolar I or II disorder later in life.

A phenomenon known as rapid cycling occurs in up to 20% of bipolar I and II patients. In rapid cycling, manic and depressive episodes must alternate frequently, at least four times in 12 months, to meet the diagnostic definition. In some cases of "ultra-rapid cycling," the patient may bounce between manic and depressive states several times within a 24-hour period. This condition is very hard to distinguish from mixed states.

Bipolar NOS is a category for bipolar states that do not clearly fit into the bipolar I, II, or cyclothymia diagnoses.

Causes & symptoms

The source of bipolar disorder has not been clearly defined. Because two-thirds of bipolar patients have a family history of affective or emotional disorders, researchers have searched for a genetic link to the disorder. Several studies have uncovered a number of possible genetic connections to the predisposition for bipolar disorder. Recent studies emphasize a hereditary connection and early research links several chromosomes, one particularly related to bipolar II, to development of the disorder. A 2003 study found that schizophrenia and bipolar disorder could have similar genetic causes that arise from certain problems with genes associated with myelin development in the central nervous system. (Myelin is a white, fat-like substance that forms a sort of layer or sheath around nerve fibers.)

Another possible biological cause under investigation is the presence of an excessive calcium build-up in the cells of bipolar patients. Also, dopamine and other neurochemical transmitters appear to be implicated in bipolar disorder and these are under intense investigation.

Over one-half of patients diagnosed with bipolar disorder have a history of substance abuse. There is a high rate of association between cocaine abuse and bipolar disorder. Some studies have shown up to 30% of abusers meeting the criteria for bipolar disorder. The emotional and physical highs and lows of cocaine use correspond to the manic depression of the bipolar patient, making the disorder difficult to diagnose.

For some bipolar patients, manic and depressive episodes coincide with seasonal changes. Depressive episodes are typical during winter and fall, and manic episodes are more probable in the spring and summer months.

Diagnosis

Bipolar disorder usually is diagnosed and treated by a psychiatrist and/or a psychologist with medical assistance. In addition to an interview, several clinical inventories or scales may be used to assess the patient's mental status and determine the presence of bipolar symptoms. These include the Millon Clinical Multiaxial Inventory III (MCMI-III), Minnesota Multiphasic Personality Inventory II (MMPI-2), the Internal State Scale (ISS), the Self-Report Manic Inventory (SRMI), and the Young Mania Rating Scale (YMRS). The tests are verbal and/or written and are administered in both hospital and outpatient settings.

Psychologists and psychiatrists typically use the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV ) as a guideline for diagnosis of bipolar disorder and other mental illnesses. DSM-IV describes a manic episode as an abnormally elevated or irritable mood lasting a period of at least one week that is distinguished by at least three of the mania symptoms: inflated self-esteem, decreased need for sleep, talkativeness, racing thoughts, distractibility, increase in goal-directed activity, or excessive involvement in pleasurable activities that have a high potential for painful consequences. If the mood of the patient is irritable and not elevated, four of the symptoms are required.

Although many clinicians find the criteria too rigid, a hypomanic diagnosis requires a duration of at least four days with at least three of the symptoms indicated for manic episodes (four if mood is irritable and not elevated). DSM-IV notes that unlike manic episodes, hypomanic episodes do not cause a marked impairment in social or occupational functioning, do not require hospitalization, and do not have psychotic features. In addition, because hypomanic episodes are characterized by high energy and goal directed activities and often result in a positive outcome, or are perceived in a positive manner by the patient, bipolar II disorder can go undiagnosed.

In late 2001, a study reported at an international psychiatric conference that impulsivity remains a key distinguishing characteristic for bipolar disorder, at least when patients are in manic phases.

Bipolar symptoms often present differently in children and adolescents. Manic episodes in these age groups typically are characterized by more psychotic features than in adults, which may lead to a misdiagnosis of schizophrenia. Children and adolescents also tend toward irritability and aggressiveness instead of elation. Further, symptoms tend to be chronic, or ongoing, rather than acute, or episodic. Bipolar children are easily distracted, impulsive, and hyperactive, which can lead to a misdiagnosis of attention-deficit hyperactivity disorder (ADHD). Furthermore, their aggression often leads to violence, which may be misdiagnosed as a conduct disorder.

Substance abuse, thyroid disease, and use of prescription or over-the-counter medication can mask or mimic the presence of bipolar disorder. In cases of substance abuse, the patient must ordinarily undergo a period of detoxification and abstinence before a mood disorder is diagnosed and treatment begins.

Treatment

Alternative treatments for bipolar disorder generally are considered to be complementary treatments to conventional therapies. General recommendations for controlling bipolar symptoms include maintaining a calm environment, avoiding overstimulation, getting plenty of rest, regular exercise , and proper diet. Psychotherapy and counseling are generally recommended treatments for the disease, whether treated alternatively or allopathically. Psychotherapy, such as cognitive-behavioral therapy, can be a useful tool in helping patients and their families adjust to the disorder and in reducing the risk of suicide. Also, educational counseling is recommended for the patient and family. In fact, a 2003 report revealed that people on medication for bipolar disorder have better results if they also participate in family-focused therapy.

Chinese herbs also may help to soften mood swings. Traditional Chinese medicine (TCM) remedies are prescribed based on the patient's overall constitution and the presentation of symptoms. These remedies can stabilize moods, not just treat swings in mood. A TCM practitioner might recommend a mixture called the Iron Filings Combination (which includes the Chinese herbs asparagus, ophiopogon, fritillaria , arisaema, orange peel, polygala, acorus, forsythia, hoelen, fu-shen, scrophularia, uncaria stem, salvia, and iron filings) to treat certain types of mania in the bipolar patient. There are other formulas for depression. A trained practitioner should guide all of these remedies. Compliance can be better with natural remedies if they work. These remedies do not flatten moods and people in manic states do not like to be suppressed.

Acupuncture can be used for treatment to help maintain a more even temperament.

Biofeedback is effective in helping some patients control symptoms such as irritability, poor self control, racing thoughts, and sleep problems. A diet low in vanadium (a mineral found in meats and other foods) and high in vitamin C may be helpful in reducing depression.

In 2003, a report stated that rhythm therapy, or simply taking steps to go to bed and wake up at consistent times each day, helps some people with bipolar disorder maintain mood stability, especially when faced with psychosocial stress .

Allopathic treatment

Allopathic treatment of bipolar disorder is usually by means of medication. A combination of mood stabilizing agents with antidepressants, antipsychotics, and anticonvulsants is used to regulate manic and depressive episodes.

Mood stabilizing agents such as lithium, carbamazepine, and valproate are prescribed to regulate the manic highs and lows of bipolar disorder:

Lithium (Cibalith-S, Eskalith, Lithane, Lithobid, Lithonate, Lithotabs) is one of the oldest and most frequently prescribed drugs available for the treatment of bipolar mania and depression. Lithium has also been shown to be effective in regulating bipolar depression, but is not recommended for mixed mania. Possible side effects of the drug include weight gain, thirst, nausea and hand tremors . Prolonged lithium use may also cause hyperthyroidism (a disease of the thryoid that is marked by heart palpitations, nervousness, the presence of goiter, sweating, and a wide array of other symptoms).

Carbamazepine (Tegretol, Atretol) is an anticonvulsant drug usually prescribed in conjunction with other mood stabilizing agents. The drug is often used to treat bipolar patients who have not responded well to lithium therapy. Blurred vision and abnormal eye movement are two possible side effects of carbamazepine therapy.

Valproate (divalproex sodium , or Depakote; valproic acid, or Depakene) is one of the few drugs available that has been proven effective in treating rapid cycling bipolar and mixed states patients. Valproate is prescribed alone or in combination with carbamazepine and/or lithium. Stomach cramps, indigestion, diarrhea, hair loss , appetite loss, nausea, and unusual weight loss or gain are some of the common side effects of valproate.

Because antidepressants may stimulate manic episodes in some bipolar patients, their use is typically short-term. Selective serotonin reuptake inhibitors (SSRIs) or, less often, monoamine oxidase inhibitors (MAOIs) are prescribed for episodes of bipolar depression. Tricyclic antidepressants used to treat unipolar depression may trigger rapid cycling in bipolar patients and are, therefore, not a preferred treatment option for bipolar depression.

Electroconvulsive therapy (ECT), has a high success rate for treating both unipolar and bipolar depression, and mania. However, because of the convenience of drug treatment and the stigma sometimes attached to ECT therapy, ECT usually is employed after all pharmaceutical treatment options have been explored. ECT is given under anesthesia and patients are given a muscle relaxant medication to prevent convulsions. The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient's head. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that this electrical current alters the electrochemical processes of the brain, consequently relieving depression. In bipolar patients, ECT often is used in conjunction with drug therapy.

Long-acting benzodiazepines such as clonazepam (Klonapin) and alprazolam (Xanax) are used for rapid treatment of manic symptoms to calm and sedate patients until mania or hypomania have waned and mood stabilizing agents can take effect. Neuroleptics such as chlorpromazine (Thorazine) and haloperidol (Haldol) also are used to control mania while a mood stabilizer such as lithium or valproate takes effect. Clozapine (Clozaril) is an atypical antipsychotic medication used to control manic episodes in patients who have not responded to typical mood stabilizing agents. The drug also has been a useful prophylactic, or preventative treatment, in some bipolar patients.

The treatment rTMS, or repeated transcranial magnetic stimulation, is a relatively new and still experimental treatment for the depressive phase of bipolar disorder. In rTMS, a large magnet is placed on the patient's head and magnetic fields of different frequency are generated to stimulate the left front cortex of the brain. Unlike ECT, rTMS requires no anesthesia and does not induce seizures.

Expected results

While most patients will show some positive response to treatment, response varies widely, from full recovery to a complete lack of response to all treatments, alternative or allopathic. Drug therapies frequently need adjustment to achieve the maximum benefit for the patient. Bipolar disorder is a chronic recurrent illness in over 90% of those afflicted, and one that requires lifelong observation and treatment after diagnosis. Patients with untreated or inadequately treated bipolar disorder have a suicide rate of 15-25% and a nine-year decrease in life expectancy. With proper treatment, the life expectancy of the bipolar patient will increase by nearly seven years and work productivity increases by 10 years.

Prevention

The ongoing medical management of bipolar disorder is critical to preventing relapse, or recurrence, of manic episodes. Even in carefully controlled treatment programs, bipolar patients may experience recurring episodes of the disorder. Patient education in the form of psychotherapy or self-help groups is crucial for training bipolar patients to recognize signs of mania and depression and to take an active part in their treatment program.

Bipolar Disorder

Bipolar disorder

A condition (traditionally called manic depression) in which a person alternates between the two emotional extremes of depression and mania (an elated, euphoric mood).

Bipolar disorder is classified among affective disorders in the American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders. The National Institute of Mental Health (NIMH) estimates that about one in one hundred people will develop the disorder, which affects some two million Americans. While this condition occurs equally in both males and females and in every ethnic and racial groups, it is more common among well-educated, middle- and upper-income persons. Those suffering from untreated bipolar disorder will generally experience an average of four depression/mania episodes in a ten-year period. However, some people go through four or more mood swings a month, while others may only experience a mood swing every five years. The onset of bipolar disorder usually occurs in the teens or early twenties.

Of all types of depressive illness, bipolar disorder is the one that is most likely to have biological origins, specifically an imbalance in the brain's chemistry. Genetic factors play an important role in the disease. In one study, one-fourth of the children who had one manic-depressive parent became manic-depressive themselves, and three-fourths of those with two manic-depressive parents developed the disorder. The likelihood of bipolar disorder being shared by identical twins is also exceptionally high. Manic depression has also been associated with the "biological clock" that synchronizes body rhythms and external events.

The depressed state of a person suffering from bipolar disorder resembles major depression. It is characterized by feelings of sadness, apathy, and loss of energy. Other possible symptoms include sleep disturbances; significant changes in appetite or weight; languid movements; feelings of worthlessness or inappropriate guilt ; lack of concentration; and preoccupation with death or suicide . When they shift to a manic state, people with bipolar disorder become elated and overly talkative, speaking loudly and rapidly and abruptly switching from one topic to another. Plunging into many work, social, or academic activities at once, they are in constant motion and are hyperactive. They also demonstrate grandiosity— an exaggerated sense of their own powers, which leads them to believe they can do things beyond the power of ordinary persons. Other common symptoms include excessive and/or promiscuous sexual behavior and out-of-control shopping sprees in which large amounts of money are spent on unnecessary items. People in a manic phase typically become irritable or angry when others try to tone down their ideas or behavior, or when they have difficulty carrying out all the activities they have begun. Mania may also be accompanied by delusions and hallucinations .

Mania creates enormous turmoil in the lives of its victims, many of whom turn to drugs or alcohol as a way of coping with the anxiety generated by their condition—61 percent of persons with bipolar disorder have substance abuse or dependency problems. In addition, 15 percent of those who fail to receive adequate treatment for bipolar disorder commit suicide. The disease may be misdiagnosed as schizophrenia , unipolar depression, a personality disorder, or drug or alcohol dependence. Individuals commonly suffer from it for as long as seven to ten years without being diagnosed or treated.

However, effective treatment is available. Lithium, which stabilizes the brain chemicals involved in mood swings, is used to treat both the mania and depression of bipolar disorder. This drug, which is taken by millions of people throughout the world, halts symptoms of mania in 70 percent of those who take it, usually working within one to three weeks—sometimes within hours. Antipsychotic drugs or benzodiazepines (tranquilizers) may initially be needed to treat cases of full-blown mania until lithium can take effect. Persons taking lithium must have their blood levels, as well as kidney and thyroid functions, monitored regularly, as there is a relatively narrow gap between toxic and therapeutic levels of the drug. Since lithium also has the ability to prevent future manic episodes, it is recommended as maintenance therapy even after manic-depressive symptoms subside. Some persons resist remaining on medication, however, either because they fear of becoming dependent on the drug or because they are reluctant to give up the "highs" or alleged creativity of the manic state. However, psychiatrists have reported instances in which lithium was not as effective after being discontinued as it had been initially.

Many great artists, writers, musicians, and other people prominent in both creative and other fields have suffered from bipolar disorder, including composers Robert Schumann and Gustav Mahler, painter Vincent van Gogh, writers Virginia Woolf and Sylvia Plath, and actresses Patty Duke and Kristy McNichol. The NIMH reports that 38 percent of all Pulitzer Prize-winning poets have had the symptoms of bipolar disorder.

Bipolar disorders

Bipolar disorders

Definition

Bipolar disorders is the name given to a group of mental disorders characterized by extreme fluctuations in
mood. People diagnosed with bipolar disorders experience moods ranging from deepest depression to mania, often with periods of less extreme moods, or even emotional stability, in between.

Description

Individuals diagnosed with bipolar disorders experience fluctuations in mood over which they have no control. All of the bipolar disorders cause great emotional distress. Even the state of elevated mood, or "mania," might sound as if it would feel good; but it is, in fact, a painful, pressured feeling that is not at all pleasurable. People with mania find their thoughts running at an unstoppable pace; they cannot sleep, often for many nights at a time. Their speech may become rapid, and they may have grandiose ideas. Often people in manic states spend money they do not have, and make important but disastrous life decisions.

Individuals in the depressed mood state experience loss of interest in activities and people. They also experience loss of appetite, difficulty sleeping, lack of sexual desire, and an extreme loss of general energy. The ability to concentrate and think clearly is also compromised. Work, social, and family relationships are always impaired. Feelings of worthlessness and helplessness are common, as is the feeling that nothing will every improve. While depressed individuals may or may not report feeling "down" or "depressed," the feelings they do experience are very painful.

The handbook used by mental health professionals to diagnose mental disorders is the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, also known as the DSM-IV-TR. It includes four basic types of bipolar disorder : Bipolar I Disorder, Bipolar II Disorder, Cyclothymia, and Bipolar Disorder Not Otherwise Specified.

Bipolar I disorder is characterized by one or more manic episodes, or so-called "mixed" episodes, which involve both manic and depressive feelings alternating rapidly, often within the same day or week. Individuals with Bipolar I disorder may also experience one or more major depressive episodes. Suicide occurs in 10-15% of individuals with this disorder.

Bipolar II disorder is characterized by the occurrence of one or more major depressive episodes, interspersed with periods of mild manic episodes referred to as "hypomania." Hypomanic episodes are similar to manic ones, but are far less intense and less severe in their consequences. In fact, individuals may not see their hypomanic episodes as a problem, feeling, instead, that they have bursts of energy in which they can accomplish a great deal.

Cyclothymic disorder is a chronic, low-level disturbance of mood, punctuated by periods of depressive symptoms and periods of hypomanic symptoms. Cyclothymia often begins early in life, and people with the disorder may not know they have it; they may simply think of themselves as sadder and/or less energetic than other people, with occasional bursts of energy.

Bipolar disorder not otherwise specified is the term used in the DSM-IV-TR for individuals who do not meet the criteria for one of the other three diagnoses, but who nevertheless experience patterns of mood swings alternating between depression and mania.

bipolar disorder

The Columbia Encyclopedia, 6th ed.

Copyright The Columbia University Press

bipolar disorder, formerly manic-depressive disorder or manic-depression, severe mental disorder involving manic episodes that are usually accompanied by episodes of depression. The term
"manic-depression"
was introduced by the German psychiatrist Emil Kraepelin in 1896. The manic phase of the disorder is characterized by an abnormally elevated or irritable mood, grandiosity, sleeplessness, extravagance, and a tendency toward irrational judgment. During the depressed phase, the person tends to appear lethargic and withdrawn, shows a lack of concentration, and expresses feelings of worthlessness, self-blame, and guilt. This dual character of the disorder has given it the name bipolar disorder, in contrast to the unipolar depression symptomatic of the majority of mood disorders. The symptoms range in intensity and pattern and may not be recognized at first. Individuals suffering from bipolar disorder may have long periods in their lives without episodes of mania or depression, but manic-depressives have the highest suicide rate of any group with a psychological disorder.

Incidence

Estimates suggest that about 2 million Americans suffer from bipolar disorders. Symptoms usually appear in adolescence or early adulthood and continue throughout life. The disorder occurs in males and females equally and is found more frequently in close relatives of people already known to have it.. It has had notable incidence among creative individuals, affecting such artists as Hector Berlioz, Gustav Mahler, Ernest Hemingway, and Virginia Woolf.

Treatment

Therapy includes lithium (to control mania and stabilize mood swings), anticonvulsant drugs such as valproate and carbamazepine, and antidepressants. Electroconvulsive therapy has been useful in cases where other treatments have had little success. Psychotherapy can provide support to the patient and the family.

Bibliography

See F. K. Goodwin and K. R. Jamison, Manic-Depressive Illness (1990); D. Healy, Mania: A Short History of Bipolar Disorder (2011); publications of the National Institute of Mental Health.

Cite this article Pick a style below, and copy the text for your bibliography.

Bipolar Disorder

UXL Complete Health Resource
COPYRIGHT 2001 The Gale Group, Inc.

BIPOLAR DISORDER

DEFINITION

Bipolar disorder is a mental condition that usually involves extreme mood swings. A person with the condition may feel happy and excited at one moment and depressed the next. The disorder was once called manic-depression. Mania is a mental disorder characterized by great excitement and sometimes uncontrolled, violent behavior. Depression (see depressive disorders entry) is characterized by persistent and long-term sadness or despair.

DESCRIPTION

Bipolar disorder affects about two million Americans. The average age at which the disorder first appears is between adolescence and the midtwenties. Sometimes a correct diagnosis of the disorder is not made for years. It is complex and difficult to identify. In one study of bipolar disorder patients, half said that they saw three or more doctors before receiving a correct diagnosis. Over one third waited more than ten years before their condition was recognized.

Psychiatrists list four types of bipolar disorder. The four types differ largely on three factors. One factor is whether mania (the highs) or depression (the lows) is more common in the patient. The second factor is how serious each condition is. The third factor is how fast the patient alternates between stages.

Patients with bipolar I disorder, for example, have extreme high periods with relatively moderate periods of depression. By contrast, those with bipolar II disorder are more likely to have severe depression, separated by relatively modest periods of mania.

A third type of bipolar disorder is called cyclothymia (pronounced siekluh-THIE-mee-uh). Patients with this condition have relatively moderate periods of both mania and depression. They may almost appear to be without either symptom for long periods of time. The fourth type of bipolar disorder is called rapid cycling. In this condition, a patient changes from periods of great energy to periods of depression fairly often, usually at least four times in a single year.

CAUSES

The cause of bipolar disorder has not yet been discovered. Many researchers believe that heredity is an important factor. Two-thirds of bipolar patients have a family history of mental disorders. Some research studies claim to have found a genetic link for bipolar disorder. Genes are the chemical units present in all cells that tell cells what functions to perform. Genes are passed down from parents to children.

Some researchers also believe that abnormal levels of certain chemicals in the body can cause bipolar disorder. For example, some studies have shown that people with bipolar disorder have abnormal levels of dopamine in their brains. Dopamine is a neurotransmitter, a chemical that carries messages in the brain.

Drug abuse may be associated with bipolar disorder also. Up to 30 percent of those who abuse cocaine also have bipolar disorder. Researchers are not sure about this connection, however. It may be that bipolar disorder leads to drug abuse, or that drug abuse leads to bipolar disorder. Or it may be that both conditions are caused by some abnormal condition in a person's body.

Bipolar disorder has also been shown to be associated with the seasons. Some patients experience mania during the summer months and depression during the winter months.

Bipolar Disorder: Words to Know

Anticonvulsant medication:

A drug used to prevent convulsions or seizures that is sometimes also effective in the treatment of bipolar disorder.

Benzodiazepines:

A group of tranquilizing drugs that have a calming influence on a person.

DSM-IV:

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the standard reference book used for diagnosing and treating mental disorders.

ECT:

Electroconvulsive shock therapy, a method for using electric shocks to treat patients with mental disorders, such as bipolar disorder.

Mania:

A mental condition in which a person feels unusually excited, irritated, or happy.

Neurotransmitter:

A chemical found in the brain that carries electrical signals from one nerve cell to another nerve cell.

SYMPTOMS

The symptoms of bipolar disorder vary depending on the part of the cycle a patient is experiencing. During a low period, the patient has low energy levels, feelings of despair, difficulty concentrating, extreme fatigue, and slower mental and physical functions.

The manic, or high, part of a cycle is characterized by feelings of happiness and well-being, lack of restraint, talkativeness, racing thoughts, reduced need for sleep, and irritability. In extreme cases, mania can be expressed in the form of hallucinations and other mental fantasies.

DIAGNOSIS

Bipolar disorder is usually diagnosed by a psychiatrist, a doctor who specializes in mental conditions. One set of tools that is often used is a series of tests of a person's mental condition. Some examples of these tests include the Millon Clinical Multiaxial Inventory III (MCMI-III), the Minnesota Multiphasic Personality Inventory II (MMPI-2), the Internal State Scale (ISS), and the Self-Report Manic Inventory (SRMI). These tests may be either verbal or written and are conducted in a hospital or a doctor's office.

Psychiatrists rely on a book called the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), in diagnosing bipolar disorder. DSM-IV is the standard reference manual for all kinds of mental disorders. It describes the conditions for which a psychiatrist should look in diagnosing a condition. The guidelines set down in DSM-IV are very clear and specific for each condition.

For example, DSM-IV defines mania as a period of abnormally intense excitement that lasts for a period of at least one week. The patient must also demonstrate at least three specific symptoms from the following list:

Inflated self-esteem

Decreased need for sleep

Talkativeness

Racing thoughts

Becoming distracted easily

Increase in desire to get specific jobs done

Unusual interest in activities that can lead to painful results

The symptoms of bipolar disorder are often different in children and adolescents. For example, their symptoms may be considerably more severe than in adults. A psychiatrist may diagnose schizophrenia (pronounced skit-suh-FREE-nee-uh, see schizophrenia entry), a severe and disabling mental disorder, rather than bipolar disorder. The symptoms of bipolar disorder in those under the age of twenty lead to many incorrect diagnoses, including attention-deficit/hyperactivity (ADHD; see attention-deficit/hyperactivity disorder entry) or conduct disorder.

Other conditions can also produce symptoms similar to those of bipolar disorder. Drug abuse is one such condition. A drug abuser cannot be examined for possible bipolar disorder until he or she has stopped using drugs. Disorders of the thyroid gland and the use of prescribed and over-the-counter medication can also produce bipolar-like symptoms.

TREATMENT

Bipolar disorder is usually treated with some form of medication. Some drugs help to elevate a person's moods during the low part of a bipolar cycle. Others help to calm the person down during the high part of a cycle. Some examples of commonly used drugs include:

Lithium. The common name for a group of chemicals that contain the chemical element lithium. These chemicals are among the oldest and most frequently prescribed of all drugs for the treatment of bipolar disorder. While they do not work equally well for all forms of the disorder, they can be very effective for many patients when taken according to the schedule prescribed by a doctor. Some side effects of lithium drugs include weight gain, thirst, nausea, and hand tremors (shaking). Long-term use sometimes leads to hyperthyroidism. Hyperthyroidism is a condition caused by an overactive thyroid gland. It can result in a variety of symptoms, both mild and serious.

Carbamazepine. Carbamazepine (pronounced KAHR-buh-MAZ-uh-peen) is an anticonvulsant drug used to prevent convulsions (spasms). It is often prescribed to patients for whom lithium treatment is ineffective. Blurred vision and other eye problems are possible side effects of carbamazepine use.

Valproate. Used primarily for the treatment of patients with rapid cycling bipolar disorder. These patients often do not respond to treatment with lithium. Side effects of valproate use include stomach cramps, indigestion, diarrhea, hair loss, appetite loss, nausea, and unusual weight loss or gain.

Antidepressants. Sometimes used to treat bipolar disorder on a short-term basis. An antidepressant is a drug that tends to overcome a person's depression and lift his or her spirits. Antidepressants are not used on a long-term basis because they may intensify the manic period in a person's bipolar cycle. That is, the person may not be depressed, but he or she may become more manic. Some examples of antidepressants used to treat bipolar disorder are the drugs known as selective serotonin (pronounced sihr-uh-TOE-nun) reuptake inhibitors (SSRIs), monoamine (pronounced mon-oh-AM-een) oxidase inhibitors (MAO inhibitors), and tricyclic antidepressants.

Electroconvulsive Shock Therapy

Bipolar disorder is sometimes treated with electroconvulsive shock therapy, or ECT. ECT is a procedure in which intense electrical shocks are administered through electrodes attached to the patient's head. The patient is first given anaesthesia (pronounced an-is-THEE-zhuh) and a muscle relaxant. The muscle relaxant prevents the patient from going into convulsions that would cause broken bones and strained muscles.

No one knows how electric shocks affects the patient's brain. In some cases, however, the treatment is able to relieve the conditions of bipolar disorder. The side effects of ECT include headaches, muscle soreness, nausea, confusion, and memory loss.

Some doctors are reluctant to use ECT unless all other treatments fail. The procedure has many critics who regard it as inhumane. Most cases of bipolar disorder now respond to some form of drug treatment, making ECT unnecessary.

Other Drugs

A variety of drugs are available for treating other aspects of bipolar disorder. For example, some patients have very severe episodes of mania or depression. They may need to have drugs to get them through the worst parts of these episodes. One group of drugs, known as benzodiazepines (pronounced ben-zo-die-A-zuh-peenz), can be used to calm a patient who is having a severe attack of mania. The drug known as clozapine (pronounced KLO-zuh-peen) can also be used to help prevent manic episodes and to treat patients who do not respond to other drugs designed to stabilize their moods.

Counseling

Counseling can also be of some help with bipolar disorder. While it cannot cure the disorder because mania and depression are caused by biological factors, patients can sometimes better understand the nature of their condition and learn to adjust to it. Perhaps most important, counseling can help patients and their families to understand the need for a person to stay on a strict schedule of drug therapy.

Alternative Treatment

Bipolar patients can often benefit from some simple suggestions, such as maintaining a calm environment, avoiding over-simulation, getting plenty of rest and regular exercise, and eating a proper diet. Some practitioners believe that Chinese herbs can soften mood swings. Biofeedback can sometimes help patients control their symptoms, such as irritability, poor self-control, racing thoughts, and sleep problems. During biofeedback a patient watches the brain waves produced when he or she is behaving a certain way. The patient than learns to adjust that behavior to produce correct brain waves. A diet high in vitamin C is thought by some to help reduce depression.

PROGNOSIS

Most patients benefit to some extent from treatment, however responses vary widely from complete recovery to no improvement at all with any form of treatment. One of the most difficult problems is to find the right drug, the right combination of drugs, and the right dosage for any one patient. Bipolar disorder is a chronic condition. That is, most patients experience the condition throughout their lives and require lifelong treatment and observation.

Suicide is common among people with severe bipolar disorder who do not receive prompt or adequate treatment. The suicide rate is 15 to 25 percent among these individuals. With proper and early diagnosis and treatment, however, it is possible for bipolar patients to live normal lives.

PREVENTION

There is currently no known way to prevent bipolar disorder, but the chances of stabilizing the condition improves considerably with proper treatment. Educating the patient about the disorder is also important. He or she can learn to recognize the signs of mania and depression and be taught how to respond to those signs.

Bipolar Disorder

Bipolar (by-POLE-ar) disorder is a condition in which periods of extreme euphoria* (yoo-FOR-ee-uh), called mania (MAY-nee-uh), alternate with periods of severe depression*. Bipolar disorder is sometimes also called manic (MAN-ik) depression.

Bipolar disorder is a type of depressive disorder*. People with bipolar disorder experience two (thus the prefix “bi”) extremes in mood; they have periods of extreme happiness and boundless energy that are followed by periods of depression. Bipolar disorder can range from severe to mild. Different forms of bipolar disorder are distinguished from one another by the severity of mood extremes and how quickly mood swings take place. For example, full-blown bipolar disorder, or bipolar I, involves distinct manic episodes followed by depression. People with this form of bipolar disorder often experience trouble sleeping, changes in appetite, psychosis*, and thoughts of suicide. Another form of bipolar disorder called bipolar II affects some people. In bipolar II the mania is not extreme and the person does not lose touch with reality but does have periods of depression. Some people also experience mixed states where symptoms of mania and depression exist at the same time, and this form may be more common in children. Other people may experience a form of bipolar disorder in which there is a rapid cycling between “up” and “down” moods with few, if any, normal moods in between. Cyclorhythmia is a condition in which there are mood swings but with milder highs and lows.

(sy-KO-sis) refers to mental disorders in which the sense of reality is so impaired that a patient can not function normally. People with psychotic disorders may experience delusions (exaggerated beliefs that are contrary to fact), hallucinations (something that a person perceives as real but that is not actually caused by an outside event), incoherent speech, and agitated behavior.

Ernest Hemingway, winner of the Nobel Prize in literature, showed signs of having bipolar disorder. So did presidents Abraham Lincoln and Theodore Roosevelt and the composer Ludwig von Beethoven. All of these men were intelligent, creative, successful individuals, but they all fought the two faces of bipolar disorder. At one moment they would be on top of the world, full of ideas and creative and physical energy. Then a few days, weeks, or months later they would be sunk in the despair and lethargy of depression.

Bipolar disorder affects about 1 out of every 100 people, or at least 2 million Americans. It affects people of all races, cultures, professions, and income levels. Men and women are affected at equal rates. Bipolar disorder tends to run in families and is believed to have an inherited genetic component. Studies on twins show that if one member of a pair of identical twins (twins who have identical genes*) has bipolar disorder, the other twin has about a 70 percent chance of also having the disorder. If one of a pair of fraternal twins (twins who do not have identical

are chemicals in the body that help determine a person’s characteristics, such as hair or eye color. They are inherited from a person’s parents and are contained in the chromosomes found in the cells of the body.

Virginia Woolf (1882–1941), the British novelist and critic, suffered from bipolar disorder. She finally succumbed to her bouts of severe depression in 1941, when she committed suicide in Sussex, England. Hulton-Deutsch Collection/Corbis

Bipolar disorder usually begins in early adulthood, although experts now recognize that younger children and teens may also have the disorder. Some children who are diagnosed with attention deficit hyperactivity disorder (ADHD)* may actually have bipolar disorder or both disorders. These children not only have symptoms of ADHD but often also have

is a condition that makes it hard for a person to pay attention, sit still, or think before acting.

symptoms such as significant and sustained tantrums, periods of anxiety* (including separation anxiety*), periods of irritability, and mood changes. With many children, mood states change rapidly and without warning. Children with bipolar disorder are beginning to be researched by psychologists* and psychiatrists* who previously did not believe that such disorders occur in early childhood.

(sy-KY-uh-trist) refers to a medical doctor who has completed specialized training in the diagnosis and treatment of mental illness. Psychiatrists can diagnose mental illnesses, provide mental health counseling, and prescribe medications.

Doctors often ask family members about the person’s symptoms, as people with bipolar disorder are often not aware of the changes they are experiencing. People with bipolar disorder have had at least one period of mania. Often after the first episode five or more years will pass before another manic or a depressive period occurs. Despite the stretches of normal moods, bipolar disorder does not go away. Instead, the time between mania and depression gets shorter and shorter, and the symptoms may become more severe. Not infrequently, bipolar disorder can lead to psychosis or to suicide. About 19 percent of people who have required hospitalization for bipolar disorder commit suicide.

Most people with severe mood swings can be helped by treatment. The drug lithium has been one of the medications of choice for treating bipolar disorder, and it is often very effective. Other medications have also have been helpful in controlling mood swings. These include various antiseizure medications (for example, valproate and carbamazepine) and antipsychotic medications. People with bipolar disorder need to continue to take their medications even when they feel normal to prevent the reoccurrence of mood swings.

Living with a loved one who has bipolar disorder can be very hard on family members.

Perhaps the most effective thing that family members can do is to help the person with the disorder get treatment. Many family members find joining a support group or participating in family therapy to be helpful in understanding and managing the impact of this difficult problem.

People who are taking about suicide need emergency help. Many telephone books list suicide and mental health crisis hotlines in their Community Service sections, or help can be obtained by calling emergency services (911 in most communities).

Book

Steel, Danielle. His Bright Light: The Story of Nick Traina. New York: Dell Publishing, 2000. Romance novelist Danielle Steel tells the true story of her son’s struggle with bipolar disorder.

Organizations

The Child and Adolescent Bipolar Foundation (CABF), 1187 Wilmette Avenue, P.M.B. #331, Wilmette, IL 60091. CABF is an organization that provides information and support for families of children who have early-onset bipolar disorder. Telephone 847-256-8525 http://www.bpkids.org